National Resource Center for Health and Safety in Child Care and Early Education (NRC)

1. 1 Preventing Childhood Obesity in Early Care and Education Programs: How to implement a new set of national standards in nutrition, physical activity, and screen time for early childhood programs National Association for the Education of Young Children (NAEYC) November 4, 2011, Orlando, FL

2. 2 National Resource Center for Health and Safety in Child Care and Early Education (NRC) Presenters Marilyn J. Krajicek, EdD, RN, FAAN Director of the National Resource Center for Health and Safety in Child Care and Early Education Danette Glassy, MD, FAAP University of Washington, Clinical Professor Mercer Island Pediatrics Sandra Cianciolo Project Coordinator for National Training Institute for Child Care Health Consultants University of North Carolina at Chapel Hill

3. 3 National Resource Center for Health and Safety in Child Care and Early Education (NRC) The Consortium: American Academy of Pediatrics (AAP) American Public Health Association (APHA) National Resource Center (NRC) for Health and Safety in Child Care and Early Education (at University of Colorado) National Training Institute (NTI) (at University of North Carolina Chapel Hill) Funded through the Maternal and Child Health Bureau Cooperative Agreement (MCHB)

4. 4 National Resource Center for Health and Safety in Child Care and Early Education (NRC) NRC Mission: To improve the quality of out-of-home child care and early education programs and support the health and safety of the children they serve.

5. 5 National Resource Center for Health and Safety in Child Care and Early Education (NRC) The NRC supports the efforts of: Child care providers Early educators Families/parents Health professionals Early childhood comprehensive systems State child care regulatory agencies State and local health departments Policy makers

6. 6 Caring for Our Children (CFOC) 3rd Ed. Caring for Our Children National Health and Safety Performance Standards for Early Care and Education Programs • 3rd edition Revision completed and published in June 2011 • 4-year revision process • 10 Technical Panels - 85 panel members - Content Experts from AAP, APHA, and subject specialists

7. 7 Caring for Our Children (CFOC) 3rd Ed. Definitive source on best practice in health and safety in early care and education settings Evidence-based Expert consensus Model for health & safety practices

8. 8 Caring for Our Children (CFOC) 3rd Ed. Contents: Chapter 1:Staffing Chapter 2:Program Activities for Healthy Development Chapter 3:Health Promotion and Protection Chapter 4:Nutrition and Food Service Chapter 5:Facilities, Supplies, Equipment & Environmental Health Chapter 6:Play Areas/ Playgrounds & Transportation Chapter 7:Infectious Disease Chapter 8: Children With Special Health Care Needs & Disabilities Chapter 9:Administration Chapter 10: Licensing & Community Action

9. Preventing Childhood Obesity in Early Care And Education Programs First spin-off from CFOC 3rd edition Released July 2010 Available in print through American Academy of Pediatrics and online at nrckids.org Spanish version available online 9

10. CFOC Nutrition Panel had primary responsibility Expert Panel members included: Pediatricians Maternal and Child Health Professionals Nutritionists Other Health Professionals Nursing, Social Work Breastfeeding Experts Physical Activity Experts Child Development Specialists Preventing Childhood Obesity in Early Care And Education Programs 10

11. Obesity 1 in 3 low income children are obese or overweight by 5 years 11

12. Health Consequences Seriously reduced quality of life Increased risk of chronic disease: Diabetes Hypertension and Cardiovascular disease GE reflux disease Obstructive sleep apnea, which can contribute to learning problems and behavior problems Asthma Increased cost of health and medical care 12

13. Obesity and Child Care Children in child care are more likely to be obese – Maher, et al, Pediatrics 2008 Aug Children in child care are sedentary for most of their time in child care (70-83%), excluding naps- Pate, et al, Pediatrics 2004 Nov only small amount (2-3%) of time in vigorous activity only 12-46 min of moderate or vigorous activity over course of 6 hr day in child care 13

14. CFOC Standards NUTRITION variety of healthy foods promote positive mealtime environment PHYSICAL ACTIVITY daily indoor & outdoor activities SCREEN TIME limited 14

15. How the Standards Address the Problem promote eating a variety of healthy foods advocate breastfeeding of infants emphasize and promote daily physical activity limit access to screen time partner with families to promote healthy eating practices and lifestyles encourage collaboration among families, caregivers, and community health partners 15

16. Examples of New and Significant Changes In CFOC 3rd Edition Related to Childhood Obesity 16 Caring for Our Children (CFOC) 3rd Ed.

17. Encourage Breastfeeding Encourage mothers to breastfeed at the child care program – provide comfortable, private areas Train caregivers/teachers to support and advocate for breastfeeding. Implement policies and procedures on handling and feeding human milk safely – reduces mother’s anxiety and promotes safety for infants 17

18. Nutrition Feed infants on cue by consistent caregiver Accommodate use of soy formula and soy milk when necessary Use 2% milk for children 12 months to 2 years, for whom overweight or obesity is a concern with written documentation from health professional 18

19. Accommodate vegetarian diets Serve small size portions Availability of age-appropriate nutritious snacks Caregivers are models of healthy eating habits Provider sits with children during meal time and encourages socialization Food is never used as a reward/punishment Nutrition 19

20. Water available throughout the day No fruit juice for children under 12 months. 100% juice limited to 4-6 ounces for children 1– 6 years of age Whole fruits encouraged Nutrition education offered to children & parents Nutrition 20

21. Physical Activity Standards 21

22. Physical Activity Promote development of infant movement skills – plenty of tummy time Promote active daily play for 1-6 year olds with: 2-3 outdoor occasions 2 or more structured activities over course of day (indoor and/or outdoor) Time for unstructured active play 22

23. Caregivers and teachers encourage and participate in physical activities: Lead structured activities Wear clothing that permits safe and easy movement Prompt children to be active 23 Physical Activity

24. Limit restrictions to movement of infants Limit time in infant equipment (bouncy seats, swings, etc) and high chairs to no more than 15 minutes (except for meals & snacks) Cribs are only for sleeping or resting Restricting active play as a punishment is not allowed 24 Physical Activity

25. Barriers to increased physical activity Structural No outdoor playground No indoor play-space for days with inclement weather Playground too small, not enough equipment- Wide variability across different centers Teacher Gatekeeper of the playground Weather: Rain/Snow Standing water, snow on playground “Extreme” heat/ smog alert or cold Wide variability in minimum temperature, From Copeland, et al, Arch Pediatr Adol Med, May 2011 25

26. Weather “STANDARD: Children should play outdoors daily when weather and environmental conditions do not pose a significant health or safety risk: Wind chill factor at or below minus 15 degrees F and heat index at or above 90°F, as identified by the National Weather Service.” 26

27. Screen Time Standards 27

28. Screen Time No TV, video, DVD and computer use under 2 years of age 2 years and older: Only 30 minutes per week of media time and only for educational/physical activity purposes Computer use – 15 minute increments; school age children may have longer for homework. Caregivers as role models – no TV watching during day 28

29. Using the Standards National and State Campaigns can use to build integrated nutrition and physical activity components in their systems. Caregivers/teachers can use to develop and implement practices and policies and use in staff training. Families can support and join with caregivers/teachers in the implementation of healthy practices. They can also reinforce at home. 29

30. Regulators can use to develop and/or improve state regulations that support the prevention of obesity and promote healthy habits. Health care professionals can assist families and providers with sound evidence-based rationale for implementing and following healthy lifestyles. Academic faculty can use standards as a resource to prepare students for entering the early childhood workplace. Using the Standards 30

31. 31 Achieving A State of Healthy Weight NRC assessed child care regulations of all States and D.C. to determine language in conformity with standards in Preventing Childhood Obesity (PCO).

32. 32 Achieving A State of Healthy Weight • Three topic areas: • Infant Feeding • Nutrition • Physical Activity

33. 33 Achieving A State of Healthy Weight • Three child care types • Child Care Centers • Large Family Child Care Homes • Small Family Child Care Homes

34. 34 Achieving A State of Healthy Weight Rating Methodology: Components Selected 275 PCO/CFOC components of standards derived Healthy Weight Advisory Committee rated components based on impact on obesity if implemented in child care (see Appendix C of report) Components divided into 3 content areas: Infant Feeding Nutrition Physical Activity/Screen Time Top 47 components selected for rating

35. 35 Achieving A State of Healthy Weight Rating Methodology (cont.): States’ Documents Verified & Vetted Most recent regulations Obesity-pertinent content Rating Scales & Rules Established 4-point scale Tailored to each component Spreadsheets Designed to Record Ratings 118 States’ documents 3 child care types

36. 36 Achieving A State of Healthy Weight Rating Methodology (cont.): Raters Trained and Reliability Tested Five 2-person teams, with 60 ratings each on same states and same components Overall average Spearman’s rho coefficients = 0.964 (p>.001) Ratings over period of 3 months 16,638 individual ratings performed Post-rating review of all ratings for consistency For states with multiple documents, a final score per component was calculated for each child care type Result = 6826 final ratings used for analysis Data Analyses The Evaluation Center of the School of Education and Human Development, University of Colorado Denver and NRC Staff

37. 37 Achieving A State of Healthy Weight Overall Rating Schema: Degree of conformity on a scale of 1-4 and color coded on charts. 1 = state regulation contradicts the component 2 = state regulation does not refer to the component 3 = state regulation partially meets component 4 = state regulation fully meets component

38. 38 Achieving A State of Healthy Weight National Exemplary State (tied with Mississippi) Delaware Strongest in Infant Feeding for all child care settings Weakest in Nutrition for Small Family Child Care

39. 39 National Resources NAP SACC: The Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program Research-tested intervention designed to enhance policies, practices, and environments in child care by improving the: nutritional quality of food served amount and quality of physical activity staff-child interactions facility nutrition and physical activity policies and practices and related environmental characteristics Primarily addresses the inter-personal and organizational levels of the socioecologic model. http://www.center-trt.org/index.cfm

40. 40 National Resources Let’s Move! Child Care http://healthykidshealthyfuture.org

41. National Resources Motion Moments Approx. 7 minutes/video Demonstrates ideas for incorporating physical activity into child care programs for infants, toddlers, and preschoolers Available at http://nrckids.org/Motion_Moments/index.htm 41

42. National Resources Healthy Child Care America www.healthychildcare.org Resources include: Caregiver Newsletter CFOC Standard of the Month http://www.healthychildcare.org/ENewsCaregiver.html#listserv 42

43. CFOC, 3rd Edition • Standard 1.6.0.1: A facility should identify and engage/partner with a CCHC who is a licensed health professional with education and experience in child and community health. The National Training Institute for Child Care Health Consultants

44. What does a CCHC do? • CCHCs have expert information, resources, and referrals to offer. • Through onsite and telephone consultation, health education, and technical assistance, CCHCs work with child care facilities to help create environments that support the healthy development of young children. The National Training Institute for Child Care Health Consultants

45. CCHCs and Nutrition/Physical Activity • CCHCs can have a role in improving nutrition and physical activity for children in child care because they: • Already established relationships • Knowledge base • Experience with training and TA The National Training Institute for Child Care Health Consultants

46. What can a CCHC do? • Partner with a center to self-assess. 2. Help the center identify a plan of action. 3. Provide training on nutrition and physical activity for children, staff and parents/guardians. 4. Develop and distribute materials or incentives. 5. Provide technical assistance. The National Training Institute for Child Care Health Consultants

47. CCHCs Promote • Breastfeeding • Physical Activity • Good Nutrition The National Training Institute for Child Care Health Consultants

48. Strategies and Interventions • Let’s Move! • NAP SACC • I Am Moving, I Am Learning • Color Me Healthy • Be Active Kids The National Training Institute for Child Care Health Consultants

49. SNAPP: Supporting Nutrition and Active Physical Play Friday, November 4th at 2:30pm Orlando Convention Center Room W311H The National Training Institute for Child Care Health Consultants

50. 50 Policy Changes & National Initiatives Licensing Toolkit Action Sheets for potential strengthening of child care regulations and practices related to preventing childhood obesity Specific sheets for: Caregivers Legislators Licensing Agencies All NRC resources available at http://nrckids.org